Knowledge and Practice of Neonatal Pain Management and Associated Factors among Health Care Providers in Neonatal Intensive Care Units of Public Hospitals in North Shoa Zone, Amhara Regional State, Ethiopia, 2023

Background Neonatal pain has been underrecognized and undertreated in many settings with the youngest children and neonates suffering the greatest consequences. Despite recent advancements in the assessment and therapy of children's pain, a knowledge-to-practice gap still exists especially in developing nations including our country Ethiopia. Objectives To assess knowledge, practice, and associated factors towards neonatal pain management among health care professionals working at neonatal intensive care units of public hospitals in North Shoa Zone, Amhara regional state, Ethiopia. Method Facility-based cross-sectional study design was conducted among health care professionals working at NICU in all public hospitals in North Shoa Zone, from May 9, 2023, to May 23, 2023. Data were collected using a self-administered questionnaire from 123 health care professionals working at NICUs in eleven public hospitals. The collected data were checked and entered into EPI data version 3.1 and then exported to SPSS version 25 for further descriptive and logistic regression analysis. Data are summarized using descriptive statistics and presented using narrations, tables, and graphs. Result The study reveals that 48% of health care professionals possessed adequate knowledge, while only 5.7% demonstrated good practices in neonatal pain management. Factors significantly associated with better neonatal pain management practices included having good knowledge of neonatal pain management (AOR = 3.36, 95% CI [1.19–9.49]), a higher educational level (AOR = 4.48, 95% CI [1.62–13.88]), and the availability of a pain scale assessment tool in the neonatal unit (AOR = 3.91, 95% CI [1.50–10.20]). Moreover, the type of profession, specifically being a nurse (AOR = 0.23, 95% CI [0.08–0.66]), was significantly associated with knowledge of neonatal pain management. Conclusion Health care professionals' knowledge and practice regarding neonatal pain management are insufficient. Multisectoral collaboration is essential to enhance their knowledge and skills and improve the availability of pain scale assessment tools and supportive materials.


Introduction
Te International Association for the Study of Pain (IASP) defnition includes the clear connection between pain and tissue damage, the existence of dualistic thinking about body and mind, and the lack of stress.It resolved between the primacy of self-assessment and the privileging of the observer's perspective [1].In 2020, the IASP revised its defnition of pain, an unpleasant sensory and emotional experience associated with actual or potential tissue damage [2].
Newborns experience acute pain during various medical procedures.Evidence demonstrates that pain control in the neonatal period is benefcial because it improves physiological, behavioral, and hormonal outcomes [3].Newborns undergo an average of 6.6 invasive procedures per day [4].
Historically, pain in children has been underrecognized and poorly treated by health care professionals, and although advances in assessment and treatment have been made in recent years, there is still approximately a gap between knowledge and practice [5].Age-appropriate pain assessment should be available, using validated assessment tools [6].Preventing pain in infants should be the goal of all caregivers because repeated exposure to pain can have serious consequences [7].
Pain assessment in nonverbal children and infants can be a very difcult task in an already subjective process [3].Pain assessment and management tools should be standardized across trusts in youth care areas [6].Tere are several validated scoring systems for assessing pain in neonates; however, there is no standardized or universal approach to pain management [3].Assessing pain in infants is notoriously difcult due to their physical, cognitive, and behavioral development.Te use of a pain rating scale ensures consistency between nurses and other clinicians and provides an accurate measure of the presence of pain, tension, or discomfort [7].Tese scales not only quantify pain but can also provide an accurate description of the impact of nonpharmacological and pharmacological management interventions on neonatal pain [8].
Multiprofessional education is highly valued and seen as having the potential to enhance the knowledge of nurses and physicians.A more refective and collaborative practice was developed following this realization [8].Clinical staf should be aware of available pain management strategies, including nonpharmacological strategies, medication dosages, and appropriate regimens for pain control in the hospital setting [6].
Pain prevention and management guidelines should include psychological, physical, and pharmacological strategies for acute and chronic pain.Health care guidelines and practice guidelines should incorporate strategies and approaches in health care settings and home use [9].
Despite strong evidence and recommendations for pain management in national and international guidelines and organizations, knowledge has not yet been translated into consistent standard care across settings.Diverse mothers, newborns, and children, where painful neonatal procedures take place [8], most pain is preventable or at least treatable.Tere are many things that primary care physicians, pediatricians, and other allied health care professionals can do to reduce or eliminate pain.Pain can be efectively managed using a wide range of pharmacological, physical, and psychological approaches [10].
Neonates at the greatest risk of neurodevelopmental impairment as a result of preterm birth (the smallest and sickest) are also those most likely to be exposed to the greatest number of painful stimuli in the NICU [7].Early exposure to painful procedures can negatively impact neurodevelopment, a greater risk of developing noncommunicable diseases (diabetes and hypertension), and other health conditions later in life [11].

Study Area.
Te study was conducted in North Shoa zone public hospital, Amhara regional state, Ethiopia.Debre Berhan is the capital city of the zone located about 120 kilometers from Addis Ababa.In the North Shoa zone, there are one comprehensive, one teaching, two general hospitals and 7 district hospitals that have neonatal care units.In these hospitals, neonatal care is given by pediatricians, general practitioners, nurses, and other health care professionals.Currently, 135 health care providers are working in the neonatal care unit.

Study Design and Period.
Institutional-based crosssectional study design was employed from May 9, 2023, to May 23, 2023.

Source Population.
All health professionals working in the neonatal intensive care unit of North Shoa zone public hospitals were the source of population.

Study Population.
Te study population was health professionals working in neonatal intensive care units in North Shoa zone public hospitals.

Inclusion Criteria.
Health professionals must have a minimum of six months of work experience in the neonatal intensive care unit (NICU).

Exclusion
Criteria.Individuals meeting the inclusion criteria but absent, on maternity leave, or on annual leave during the data collection, and those with less than six months of work experience were excluded from the study.

Sample Size Determination.
We determined the sample size utilizing Epi Info 7.2.6 software, assuming a 51% prevalence of insufcient knowledge about pain evaluation based on a study conducted in Turkey [12], with a 5% margin of error and a 95% confdence interval.Te calculated sample size was 384.However, considering that there are only 135 health professionals currently working at the neonatal intensive care unit (NICU) in the study area, we decided to include all of them in our study.

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Pain Research and Management

Data Collection Methods
Data were collected using a self-administered questionnaire adapted from previous research [14,15].Te developed tool in the English language comprised four sections, encompassing sociodemographic factors, knowledge, practices, and organizational factors.Te data were gathered from 123 health care providers stationed at 11 public hospitals with neonatal intensive care units.Inadequate knowledge included those professionals who scored below 80% on the knowledge item.
Good practice included those health professionals who scored equal to or greater than 80% of practice questions.
Poor practice included those professionals who scored below the 80% for practice-related questions.
Health care professionals included nurses, general practitioners, pediatricians, and child health specialists.
Neonatal pain management refers to assessing the degree of pain in neonates and treating it with nonpharmacological and pharmacological measures as well as applying preventive measures.
Junior health care professionals included those people with an experience level of less than 4 years.
Senior health care professionals included those people with an experience of greater than 4 years.

Data Process and Analysis.
Data were entered into Epi data 3.1 and checked for completeness and consistency.Subsequently, the information was transferred to SPSS version 25 software for subsequent analysis.Te normality of data distribution was also checked, and data adjustments were made when needed.
Analytical methods were used to identify factors that predict health professionals' knowledge and practice of neonatal pain management.Terefore, the data were ftted to a logistic regression model.Predictor variables were identifed in two steps.First, bivariate analysis was performed to identify candidates of multivariable logistic regression analysis and then the identifed candidates were included in multivariate analysis to control for confounding factors.Te existence and magnitude of associations were established through odds ratios, 95% confdence intervals (CI), and the corresponding p values.Ultimately, the fndings were summarized and presented through statements, tables, and graphs, utilizing adjusted odds ratios and their respective 95% CIs.

Data Quality Control.
Te instrument underwent a pretest on a 5% sample in hospitals outside of the study area.After the pretest, essential modifcations were made to improve the tool's efciency before initiating the actual data collection process.Torough training was conducted for both the data collectors and supervisors.Supervisors conducted daily reviews and checks of the questionnaires to ensure their completeness and relevance.Te tools' reliability and convergent validity were also evaluated.

Ethical Considerations.
Ethical approval was obtained from Debre Berhan University, Asrat Woldeyes Health Sciences Facility, and the Institutional Ethics Review Board (IRB-179).Ofcial authorization and support documents are written for the respective medical and administrative facilities.Informed consent was obtained from each study participant.Before data collection, study participants were informed about the purpose of the study and their right to refuse participation.Additionally, study participants were informed that the information obtained would be kept confdential throughout this study.For confdentiality purposes, the names of the participants were not included in the questionnaire.Te collected data were kept confdential and used only for the study.Tis study was conducted following the Declaration of Helsinki.

Sociodemographic Characteristics of Health Care
Professionals.A total of 131 health care professionals participated in this study yielding a response rate of 123 (94%).Te mean age of the participants was 30.91 years with a minimum of 24 and a maximum of 43 and ± SD3.785.Additionally, 63/123 (51.8%) were nurses, and 60/123 (48.2%) were medical doctors.Regarding professional experience, junior level accounts for 47.2% and seniors account for 52.8% (see Table 1).

Factors Associated with Knowledge of Health Care Professionals towards Neonatal Pain
Management.Among study participants 42.3% of health professionals responded that there was no clear guideline/protocol for neonatal pain management, 52.8 had neonatal pain scale assessment tools in the unit, and 47.2% had pain management in-service training.
Anti-pain was available in 82.9% of neonatal care units and 34.45% of them had palliative care training (see Table 2).

Knowledge of Health Care Professionals on Neonatal Pain
Management.Accordingly, in this study, 59/123 (48%) of the study participants had adequate knowledge of neonatal pain management, while others had inadequate knowledge (see Figure 1).

Pain Research and Management
Regarding knowledge assessment tools, health care professionals were more agreed on the term newborn feel pain compared to preterm which was 94.3% and 92.6%, respectively, and 86.7% agreed that the pain assessment scale is important to practice.Only 65% of them agreed that pain in neonates harmed their development (see Tables 2 and 3).

Practice of Health Care Professionals on Neonatal Pain
Management.According to this study, 7/123 (5.7%) of the study participants had good practice concerning neonatal pain management, while 116/123 (94.3%) of them had poor practice (see Figure 2).
Regarding the practice of assessment tools, only 7.3% always practiced assessing pain through facial expressions and 41.46% practiced it occasionally.About the scale rating tool, 11.38% of them practiced always and 26% practiced a few times.
Regarding pain control practices, only 13.8% practiced breastfeeding to relieve pain and 9.7% of them never practiced it, and 34.14 % of them never used sucrose/glucoseto relieve pain, while 30.4% health care providers have never prescribed opioids when needed for pain relief (see 1).

Factors Associated with Knowledge of Health
Care Professionals on Neonatal Pain Management.Each outcome variable is tested for the presence of association using chi-square, and those who had association and p value less than (p < 0.25) bivariate logistic regression were selected as candidates for multiple regression to determine the predictor variables of neonatal pain management of health care professionals.Among those predictors, the type of profession, presence of guidelines, pain scale availability, and pain education at higher education were associated with knowledge of health Accordingly, the odds of having adequate knowledge of neonatal pain management among health care professionals who had neonatal pain management guidelines in the neonatal unit is 3.365 times higher than compared to those who had no guideline (AOR 3.362 (1.190-9.496)), the odds of having adequate knowledge towards neonatal pain management among health care professionals who had adequate education to manage neonatal pain is 4.478 times higher than compared to who had no adequate education (AOR � 4.478, CI (1.624-13.884)),and the odds of having sufcient knowledge of neonatal pain management among health care professionals who had a pain scale assessment tool in the neonatal unit are 3.913 more likely compared to those who had no pain scale tool (AOR 3.913(1.500-10.204).Te study also revealed that nurses were 76.7% less likely to have complete knowledge of pain management in newborns than doctors (AOR � 0.233(0.082-0.664)(see Table 4).

Factors Associated with the Practice of Health Care Professionals on Neonatal Pain Management.
Due to low health care professional neonatal pain management practices, 7/ 123 (5.7%), not all variables met the chi-square assumption; therefore, each variable was examined of the associations present in the Fisher exact test, and data are adapted to this type of test.Finally, continuing education, availability of NICU pain assessment tools, and palliative care were signifcantly associated with health care professionals' practice of neonatal pain management (see Table 5).

Knowledge of Health Care Professionals on Neonatal Pain
Management.In this investigation, health care professionals demonstrated a comprehensive understanding of pain management in newborns, registering at 48% with a confdence interval of (32-56).Tis fnding was found to be consistent with a study conducted in Turkey, where 51% of participants reported insufcient knowledge regarding pain assessment and management [12].
On the other hand, a descriptive cross-sectional study conducted in Kigali, focusing on neonatal pain management among nurses and midwives in two hospitals, revealed that a majority (74.2%) exhibited limited knowledge about pain in newborns and its management [9] which is found to be above our fnding.Tis discrepancy might be due to sociodemographic diferences among the study participants and other study setting-related issues.
Te outcome of our study indicates a lower percentage compared to studies conducted in Ethiopia, specifcally in Addis Ababa, West Oromia, and Mekele, where 68.7%, 62.6%, and 58.6% of nurses demonstrated sufcient knowledge of pain management, respectively [13,16,17].Tis disparity could be attributed to the fact that the aforementioned studies exclusively focused on nurses working in urban hospitals, whereas our research included doctors, midwives, and nurses working in neonatal intensive care units (NICUs) at primary hospitals.
In the evaluation of knowledge assessment tools, health care professionals demonstrated a higher consensus on understanding pain in full-term infants compared to preterm infants, with agreement percentages of 94.3% and 92%, respectively.Tere is an observed discrepancy in the management of newborns compared to full-term infants, and only 65% of health care professionals are aware of the detrimental efects of painful procedures on their development.Consequently, pain tends to be overlooked in this particular population.Tese fndings align with studies conducted in Ethiopia, specifcally in Addis Ababa and western Oromia [13,16].

Knowledge Associated Factors of Health Care Professionals on Neonatal Pain Management. Te fndings of this study
indicate that factors such as sufcient education, the presence of guidelines within the facility, the availability of pain scale assessment tools in the unit, and the specifc profession of health care professionals are linked to their knowledge of neonatal pain management.
Accordingly, the odds of having adequate knowledge of neonatal pain management among health care professionals who had neonatal pain management guidelines in the neonatal unit are 3.37 times higher compared to those who had no guideline AOR 3.362 (CI: 1.190-9.496).Tis is consistent with a study performed in Turkey where the availability of guidelines at the NICU was directly related to the knowledge of health care professionals on pain management [12].Tis linkage may be justifed by the fact that guidelines serve as structured reference materials, providing standardized information and protocols.Health care professionals are likely to enhance their understanding and adherence to best practices when clear guidelines are accessible, contributing to improved knowledge and competency in neonatal pain management.
Te observed increase in the odds of having good neonatal pain management knowledge among health care professionals who had adequate education to manage neonatal pain (AOR � 4.478, CI: 1.624-13.884)can be justifed by the pivotal role of education in shaping health care professionals' understanding and competence in neonatal care.Adequate education likely provides professionals with a solid foundation of knowledge and skills necessary for efective pain management in neonates.Tis fnding aligns with a study conducted in Addis Ababa and West Oromia, where a positive association was identifed between having adequate knowledge and better neonatal pain management knowledge [13].Te consistent pattern across studies underscores the importance of education as a key determinant in promoting profciency and expertise in neonatal pain management among health care professionals.
Te observed odds, where nurses are 76.7% less likely to have adequate knowledge of neonatal pain management compared to medical doctors (AOR � 0.233, CI: 0.082-0.664),may be justifed by the variations in educational backgrounds, training, and specialization between the two professions.Medical doctors typically undergo extensive medical education and training, which may encompass a more comprehensive understanding of neonatal care, including pain management.Additionally, the nature of their roles and responsibilities in patient care may expose doctors to a wider range of medical knowledge and experiences compared to nurses.Tis diference in educational and professional factors could contribute to the signifcant contrast in the likelihood of having adequate knowledge between the two professions.
Te substantial increase in the odds of having adequate knowledge about pain management in newborns, with a 3,913 times higher likelihood, among health care professionals who had a pain assessment tool in the neonatal unit compared to those without such tools (AOR 3.913, CI: 1.500-10.204),can be justifed by the instrumental role that these tools play.Pain assessment tools provide a systematic and standardized approach to evaluating pain in neonates, ofering health care professionals a tangible and structured means to identify and address pain.Te availability of such tools likely enhances professionals' familiarity with efective pain management strategies, contributing to the signifcant diference in knowledge levels observed between those with and without access to pain assessment tools.

Practice of Health Care Professionals on Neonatal Pain
Management.In this study, about 5.7% of health professionals had good neonatal management practice with CI Pain Research and Management (1.6-10.6)which is lower than a study performed in Rwanda and West Ormia (15.2%) and 32.2% of health providers have good neonatal pain management practice, respectively [9,18].Te possible justifcation for this discrepancy could be due to the variation in study settings and the use of modifed tools from these studies.
Regarding pain management practices, only 13.8% practiced breastfeeding to relieve pain, 9.7% of them never practiced, and sucrose/glucose was never practiced to relieve pain in 34.14% of health care providers as well they never prescribed opioids when necessary to relieve pain in 30.4%, indicating that there is a low practice of both nonmedication and medication use to relieve neonatal pain which is comparable to a study performed in West Oromia [18].Te observed patterns may be indicative of a broader issue, such as a lack of awareness, training, or institutional protocols, emphasizing the need for targeted interventions and education to enhance neonatal pain management practices among health care providers.
In this study, having palliative care and in-service pain management training were signifcantly associated with good neonatal pain management practice.Tis is found to be consistent with a study performed in West Oromia where nurses with adequate knowledge were more likely to adopt good neonatal pain management practices than those without adequate knowledge [13] and with a study conducted in Addis Ababa that showed nurses applying neonatal pain management policies were more likely to implement good practices in neonatal pain management [16].Tese consistent fndings across studies underscore the crucial role of education and training in shaping health care professionals' practices in neonatal pain management.

Conclusion
In this study, health care professionals demonstrated a 48% understanding of neonatal pain management, lower than studies in Turkey and Rwanda.Factors infuencing knowledge included education, the presence of guidelines, and the specifc profession.Nurses were 76.7% less likely to have adequate knowledge compared to medical doctors, emphasizing the need for targeted interventions.
Te study found associations between having guidelines and education with better knowledge.Te odds of adequate knowledge were 3.37 times higher among those with guidelines, aligning with fndings in Turkey.Additionally, the low prevalence of good neonatal pain management practices suggests a need for increased awareness and training.Te positive impact of palliative care and in-service pain management training underscores the critical role of education in shaping health care professionals' practices.

Recommendations
For the Ministry of Health, Limited research parallel to our study makes it difcult to discuss in detail.

Strengths of the Study.
It is a pioneer study in neonatal pain management involving health care professionals as a team in our country.

( 1 )( 1 )( 1 )( 1 )designs 8 .
Providing related training for professionals and improving the distribution of supporting guidelines and tools For Debre Berhan University, Developing supportive guidelines and tools and providing training regularly (2) Doing regular supervision and mentorship to see efectiveness For Zonal Health Bureau, Facilitating and providing regular training and ensuring that professionals adhere to developed guidelines (2) Development of consistent guidelines for neonatal pain management by the MOH and the concerned body For researchers, Te study was done with the limitation of a small sample size, so we recommend at large scale by using better study Strengths and Limitations of the Study 8.1.Limitations of the Study.Te practice was assessed by a self-administered questionnaire; it would be better if it was supported with qualitative data.

Table 1 :
Sociodemographic characteristics of health care professionals towards neonatal pain management among health care providers working at NICU of North Shoa zone public hospitals, Amhara regional state, Ethiopia, 2023GC.

Table 2 :
Factors associated with knowledge and practice of health care professionals towards neonatal pain management among health care providers working at NICU of North Shoa zone public hospitals, Amhara regional state, Ethiopia, 2023GC.

Table 3 :
Knowledge characteristics of neonatal pain management among health care providers working at NICU of North Shoa zone public hospitals, Amhara regional state, Ethiopia, 2023GC.Practice of health care professionals on neonatal pain management among health care providers working at NICU of North Shoa zone public hospitals, Amhara regional state, Ethiopia, 2023GC.

Table 4 :
Factors associated with knowledge of health care professionals towards neonatal pain management among health care providers working in NICU of North Shoa zone public hospitals, Amhara regional state, Ethiopia, 2023GC.

Table 5 :
Factors associated with practice status of health care professionals towards neonatal pain management among health care providers working at NICU of North Shoa zone public hospitals, Amhara regional state, Ethiopia, 2023GC.